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CPT Codes for Pathology Procedures
Surgical pathology codes (CPT 88300–88309) represent six distinct levels of specimen examination, classified from Level I to Level VI. Each level corresponds to the complexity and type of tissue evaluated during a surgical procedure. These codes are used to report the gross and microscopic examination of surgically removed specimens, ranging from simple tissues to highly complex specimens requiring detailed analysis.
| CPT Code | Description |
|---|---|
| 88302 | Surgical pathology, gross and microscopic examination; level II. This includes basic tissue examination with both gross and microscopic review for relatively simple specimens. |
| 88304 | Surgical pathology, gross and microscopic examination; level III. More complex specimens require greater evaluation than 88302. |
| 88305 | Surgical pathology, gross and microscopic examination; level IV. This is the most commonly used code for routine biopsies such as skin, gastrointestinal, or cervical biopsies. It reflects moderate complexity. |
| 88307 | Surgical pathology, gross and microscopic examination; level V. High complexity specimens such as large resections or more involved tissue analysis. |
| 88309 | Surgical pathology, gross and microscopic examination; level VI. The most complex specimens evaluated included extensive tissue or tumor resections. |
| 88300 | Surgical pathology, gross examination only (specimen identification/description; no microscopy). This code is used when only a gross examination of a specimen is performed without microscopic analysis. |
Key Points :
- These codes reflect increasing levels of specimen complexity and the extent of pathologic examination.
- The choice of code is based on specimen type and level of microscopic complexity, not on the number of slides or blocks.
- Accurate documentation of the specimen type (e.g., “colon biopsy” vs. “biopsy”) is critical to support the selected CPT code.
- Code 88305 is the workhorse code, capturing many routine biopsy evaluations.
- Gross-only examination (88300) is rarely used unless microscopic evaluation is specifically not performed.
CPT Codes 88312 to 88319 – Staining procedures
Pathologists examine surgically removed tissues or specimens under a microscope to diagnose diseases. In some cases, they use special chemical stains to highlight specific cellular structures, chemical components, or microorganisms within the tissue, enhancing visibility and diagnostic accuracy. CPT codes 88312–88319 are used to report these specialized staining procedures performed in surgical pathology.
| CPT Code | Description |
|---|---|
| 88312 | Special stains (e.g., for microorganisms, enzyme constituents), each specimen. Used to highlight specific tissue components for diagnostic purposes. |
| 88313 | Histochemical staining with frozen section(s). Applies to stains done on frozen tissue sections during intraoperative consultation. |
| 88314 | Histochemical staining with frozen sections, including interpretation and report. Includes both the staining procedure and the professional interpretation. |
| 88315 | Determinative histochemistry or cytochemistry for enzyme constituents, each specimen. Technique used to identify enzymes or other chemical components in tissues or cells. |
| 88317 | Special stains for microorganisms were performed on paraffin sections. Used to detect microorganisms in formalin-fixed tissues. |
| 88318 | Special stains for connective tissue on paraffin sections. Used to identify connective tissue components like collagen or elastin. |
| 88319 | Other determinative histochemistry or cytochemistry for enzyme constituents, per specimen. Covers additional enzyme or chemical staining techniques not specified elsewhere. |
CPT Code 88346 – Immunofluorescence
CPT code 88346 refers to the immunofluorescence technique used in surgical pathology to enhance the visualization of cellular or tissue components. This code is used for procedures when a laboratory professional performs direct or indirect immunofluorescence using a single antibody stain on a surgically removed tissue or specimen. It is commonly used to identify specific antigens within tissues, aiding in accurate disease diagnosis and classification.
Pathology CPT Codes for Organ/Disease Panels
CPT Code 80053 – Comprehensive Metabolic Panel (CMP)
CPT 80053 refers to the Comprehensive Metabolic Panel (CMP), a routine blood test that evaluates 14 different substances in the blood, including electrolytes, enzymes, proteins, and minerals.
This panel provides critical insights into a patient’s fluid and electrolyte balance, kidney and liver function, and overall metabolic health. Pathologists and clinicians commonly use it to detect conditions affecting the liver, kidneys, or metabolism, and it is essential for assessing general health status.
CPT Code 80061 – Lipid Panel
CPT 80061 is used for the Lipid Panel, a group of blood tests designed to assess levels of cholesterol and triglycerides—key indicators of lipid metabolism.
This test helps identify lipid disorders and assess a patient’s risk of cardiovascular disease. Pathologists use this code for billing purposes when performing lipid profiling to support clinical decisions around heart health and cholesterol management.
Pathology CPT codes for Hematology & Coagulation Procedures
CPT Code 85018 – Hemoglobin Measurement
CPT Code 85018 is used to claim the quantitative measurement of hemoglobin in a blood sample. Hemoglobin is the oxygen-carrying protein in red blood cells, responsible for transporting oxygen from the lungs to the rest of the body.
This test is essential for diagnosing anemia and monitoring chronic conditions related to blood oxygen levels.
CPT Code 85027 – Complete Blood Count (CBC) without Differential
CPT 85027 covers a Complete Blood Count (CBC) that does not include a differential count of white blood cells. This test evaluates key blood components, including:
- Red blood cells (RBCs)
- White blood cells (WBCs – total only)
- Platelets
- Hemoglobin levels (typically measured via spectrophotometry)
This CBC provides a broad view of a patient’s hematologic health and is frequently used in routine screenings and diagnostic evaluations.
Pathology CPT Codes for Chemistry Procedure Claims
CPT Code 83036 – Hemoglobin A1C Test (HbA1c)
CPT Code 83036 is used for claiming the Hemoglobin A1C test, which evaluates average blood glucose levels over a 2–3 month period. It is a critical diagnostic and monitoring tool for Type 1 and Type 2 diabetes.
Normal A1C levels are generally considered below 7%. This test provides long-term insight into a patient’s glycemic control.
CPT Code 83540 – Serum Iron Test
CPT Code 83540 refers to the claim for the measurement of iron levels in the blood serum. Iron is vital for producing hemoglobin and supporting oxygen transport.
This test helps detect iron deficiency, anemia, or iron overload (e.g., hemochromatosis).
CPT Code 83735 – Magnesium Level Test
CPT 83735 is used when a magnesium analysis is performed on a patient sample (usually blood).
Magnesium is crucial for neuromuscular function, bone health, and blood glucose regulation. Abnormal levels can indicate issues such as kidney dysfunction, malabsorption, or electrolyte imbalances.
CPT Code 84443 – Thyroid Stimulating Hormone (TSH) Test
CPT Code 84443 is used to report the TSH blood test procedure, which evaluates thyroid function by measuring levels of thyroid-stimulating hormone produced by the pituitary gland.
TSH helps regulate thyroid hormone production, which controls the body’s metabolism, energy levels, and temperature.
Pathology CPT codes for Urinalysis Procedures
CPT Code 81001 – Urinalysis, Automated with Microscopy
CPT Code 81001 covers a routine urinalysis performed using automated equipment with microscopic examination.
This test evaluates:
- Color and clarity of urine
- Presence of cells, crystals, casts
- Chemical properties such as glucose, protein, nitrites, and leukocyte esterase
It’s primarily used to screen for urinary tract infections (UTIs), kidney disorders, or metabolic conditions.
CPT Code 81003 – Automated Urinalysis Using Dipstick
CPT Code 81003 refers to an automated urinalysis performed using a dipstick and mechanical reader, without microscopic analysis.
The test assesses parameters like:
- Leukocytes
- pH levels
- Specific gravity
- Protein or glucose presence
This fast and efficient test supports the diagnosis of urinary and renal issues.
Pathology CPT Codes for Cytopathology Procedures
| CPT Code | Description |
|---|---|
| 88164 | Manual screening of a cytopathology slide with reporting of results using the Bethesda System, under physician supervision. |
| 88165 | Manual initial screening and then manual rescreening of the same cervical or vaginal cytopathology slide. |
| 88166 | Manual screening followed by computer-assisted rescreening performed by a pathologist to improve accuracy. |
| 88167 | Manual screening followed by computer-assisted rescreening, including additional cell selection techniques. |
CPT Codes 88164–88167 – Cervical or Vaginal Cytopathology
CPT codes in the 88164–88167 range describe various Pap smear (Papanicolaou test) techniques for examining cervical or vaginal cytology slides under physician supervision.
These tests help detect precancerous changes, infections, and cervical abnormalities, and are essential components of routine women’s health screenings.
Pathology CPT Codes for Molecular Procedures
CPT Code 81206 – BCR/ABL1 Gene Fusion Analysis
CPT code 81206 is used to report a molecular diagnostic test that detects the BCR/ABL1 gene fusion, a specific genetic abnormality often associated with certain types of leukemia, including chronic myeloid leukemia (CML) and some forms of acute lymphoblastic leukemia (ALL).
This gene fusion occurs due to a chromosomal translocation involving chromosome 22, commonly referred to as the Philadelphia chromosome. The test may be performed as either a qualitative or quantitative analysis.
Regardless of the method used, CPT 81206 covers both testing variations and is essential for the diagnosis, monitoring, and treatment planning of affected patients.
CPT Code 81241 – Factor V Leiden Mutation Analysis
CPT code 81241 is used to report a molecular test that detects the presence of the Factor V Leiden mutation, a common inherited thrombophilia (blood clotting disorder).
This genetic mutation increases a person’s risk of developing abnormal blood clots, deep vein thrombosis (DVT) or pulmonary embolism (PE). Pathologists perform this test to help physicians assess genetic risk factors for thrombosis and guide preventive or therapeutic decision-making, especially in patients with a personal or family history of clotting events.
